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Background

Dental caries

Dental caries (tooth decay) is a large public health problem in the United Kingdom. It is one of the most common diseases affecting childhood and can cause considerable pain and suffering for the child and time off school. It follows social gradients with the most deprived being the most affected, and estimated NHS costs for treating decayed permanent teeth in 12-year-olds alone at approximately £33 million per year. 

Traditional treatment for tooth decay, usually involves late detection and then treatments using a local anaesthetic injection, drilling and removal of all parts of the tooth affected with decay, and placement of a filling material. The dental drill and injections are two of the main reasons that invoke fear in patients and deter them from visiting the dentist. Furthermore, dental fillings do not last forever, and replacements are required periodically, leaving a lasting burden for children into adulthood and on society.

Minimum intervention dentistry

Minimum Intervention dentistry (MID) is a modern approach to managing tooth decay, involving early detection, diagnosis, prevention, restoration when required, and review. Tooth decay when detected in its early stages can be stopped with preventive MID strategies, such as sealing, without the need to drill or fill.  For advanced stages of tooth decay where a cavity is present MID will involve restoring using minimally invasive techniques (not requiring removal of all the affected tooth), and then placing the smallest sized filling, thereby preserving as much of the natural tooth as possible. This MID approach being patient-centred and tooth preserving, has potential major benefits over the traditional invasive approach. 

Before running a decisive trial in primary care general dental practice to prove if MID for treating tooth decay in children’s permanent teeth compared to current standard practice is more effective a feasibility study was required and undertaken. 

Methodology

We firstly conducted a scoping review on MID to help identify domains and component procedures of an MID intervention. This scoping review was completed and identified 64 relevant articles. The majority of these consisted of opinion papers. The literature described a wide range of component procedures that may be included in an MID intervention. No empirical literature was identified that evaluated a whole MID approach to managing caries. 

The scoping review highlighted a paucity of evidence supporting the effectiveness of an MID approach for children with dental caries in primary care dental practice and identified some potential barriers to the implementation of MID. Five themes were identified from the scoping literature. These pertained to the evidence base, clinician attitude and skills, practice implementation, acceptability, and contextual factors. There were several research gaps identified for each theme. Scoping review findings helped to refine the MID intervention used in the feasibility study. 

In the next stage, 46 Dental Professionals (DPs) from ten NHS dental practices were trained in MID and were asked to deliver MID to children (aged 6-16 years) with tooth decay in their permanent molars. Clinicians, children, and parents completed questionnaires on fidelity, quality of life, dental anxiety, and treatment acceptability. A sample of participants (24 dental professionals, 9 children and 9 parents) also took part in semi-structured qualitative interviews exploring their experiences of taking part in the study and MID.   

Study updates

The study was completed, and of the 86 courses of treatment started, four participants failed to complete their course of treatment. Interviews with children/parents confirmed positive support for participation and MID, and highlighted resources that may be desirable such as videos for patient information.

The majority of dental professionals approached were supportive of practice-based research, and valued training in MID. Facilitators such as wider practice team involvement, MID training incorporating scenario-based training, and practice organisation, were seen as helping practices with research delivery. They highlighted the competing pressures of conducting research whilst trying to deliver routine NHS dental care. 

Children and parents were very supportive of MID and oral health research, they were accepting of MID in managing children with dental caries, and the data collection forms were not a burden. Supporting video resources to explain the MID intervention would be helpful and may raise awareness for children and carers. Whilst acceptability of data collection instruments was positive, dental practices should be supported to complete CRSA forms and help with fidelity of the intervention. 

This study showed that MID for children with dental caries is an acceptable intervention and, with refinements to study design, can be delivered in a trial setting across varied primary care dental practices. Further research is needed in this setting to determine the clinical and cost effectiveness of MID for children with caries in their permanent teeth. 

Project group